Jurnal PSM

RESEARCH ARTICLE
Community participation in health services

development, implementation, and
evaluation: A systematic review of
empowerment, health, community, and
process outcomes
Victoria Haldane1☯, Fiona L. H. Chuah1☯, Aastha Srivastava1, Shweta R. Singh1, Gerald C.
a1111111111 H. Koh1, Chia Kee Seng1, Helena Legido-Quigley ID1,2*
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1 Swee Hock School of Public Health, National University of Singapore, Singapore, 2 Department of Global
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Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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a1111111111 ☯ These authors contributed equally to this work.
* Helena_Legido_Quigley@nuhs.edu.sg
OPEN ACCESS
Abstract
Citation: Haldane V, Chuah FLH, Srivastava A,
Singh SR, Koh GCH, Seng CK, et al. (2019)
Community participation in health services Background
development, implementation, and evaluation: A Community participation is widely believed to be beneficial to the development, implementa-
systematic review of empowerment, health,
community, and process outcomes. PLoS ONE 14
tion and evaluation of health services. However, many challenges to successful and sustain-
(5): e0216112. https://doi.org/10.1371/journal. able community involvement remain. Importantly, there is little evidence on the effect of
pone.0216112 community participation in terms of outcomes at both the community and individual level.
Editor: Cathy Maulsby, Johns Hopkins School of Our systematic review seeks to examine the evidence on outcomes of community participa-
Public Health, UNITED STATES tion in high and upper-middle income countries.
Received: March 12, 2018
Accepted: April 15, 2019 Methods and findings

Published: May 10, 2019 This review was developed according to PRISMA guidelines. Eligible studies included those
Copyright: © 2019 Haldane et al. This is an open that involved the community, service users, consumers, households, patients, public and
access article distributed under the terms of the their representatives in the development, implementation, and evaluation of health services,
Creative Commons Attribution License, which
policy or interventions. We searched the following databases from January 2000 to Septem-
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
ber 2016: Medline, Embase, Global Health, Scopus, and LILACs. We independently
author and source are credited. screened articles for inclusion, conducted data extraction, and assessed studies for risk of
Data Availability Statement: All relevant data are
bias. No language restrictions were made. 27,232 records were identified, with 23,468 after
within the paper and its Supporting Information removal of duplicates. Following titles and abstracts screening, 49 met the inclusion criteria
files. for this review. A narrative synthesis of the findings was conducted. Outcomes were catego-
Funding: This research was supported by the rised as process outcomes, community outcomes, health outcomes, empowerment and
National University Health System (NUHS) and stakeholder perspectives. Our review reports a breadth of evidence that community involve-
National University of Singapore through the
ment has a positive impact on health, particularly when substantiated by strong organisa-
Community Based Healthcare Innovation
Programme, and also by the NUHS Singapore tional and community processes. This is in line with the notion that participatory approaches
Population Health Improvement Centre (SPHERiC). and positive outcomes including community empowerment and health improvements do not
PLOS ONE | https://doi.org/10.1371/journal.pone.0216112 May 10, 2019 1 / 25

Community participation in health services: A systematic review on outcomes
Competing interests: The authors have declared occur in a linear progression, but instead consists of complex processes influenced by an
that no competing interests exist. array of social and cultural factors.
Conclusion
This review adds to the evidence base supporting the effectiveness of community participa-
tion in yielding positive outcomes at the organizational, community and individual level.
Trial registration
Prospero record number: CRD42016048244.
Introduction
Community participation came to the fore with the 1978 Alma Ata declaration, which framed
the community as central to the planning, organizing, operation and control of primary health
care [1]. In recent years, community participation has once again emerged as a priority in
health globally following the initiation of the new Sustainable Development Goals. In line with
the SDGs, integrated people-centered health services are key to achieving universal health cov-
erage and attaining this goal requires participatory approaches [2]. Furthermore, with the
rapid increase of chronic disease burden worldwide, intersectoral approaches encompassing
community participation and engagement has been identified as key for implementing strate-
gies in health promotion and the prevention and control of chronic diseases [3].
Over the decades, there has been much exploration, development, and debate on ways to
conceptualize meaningful community participation in health services[4]. Beyond the use of
community participatory approaches to promote the effectiveness of health programs imple-
mented, engaging communities effectively is believed to have a positive impact on social capi-
tal, leading to enhanced community empowerment, and ultimately improved health status and
reduced health inequalities [5]. However, despite the wide acceptance of community involve-
ment in theory and practice, there still remains many challenges, both structural and practical,
to successful implementation [5]. Furthermore, there is little concrete evidence on the effec-
tiveness of community involvement programs, particularly on improvements in intermediate
and long-term outcomes, including health related outcomes [6]. Much of the research done on
community participation has also focused on low and middle income countries despite evi-
dence of its universal utility in improving health [7]. To address this gap, this systematic review
aims to examine the evidence on community involvement and participation from studies that
report on program outcomes in high and upper-middle income countries.
Previous systematic reviews of community participation outcomes have focused on mother
and child health [2], and rural health [8]. One systematic review explored health and social
outcomes of participatory approaches in the United Kingdom [9], and one systematic review
of literature between 1966 to 2000 reported on the effects of involving patients in the planning
and development of healthcare [10]. To our knowledge, there are no reviews of the existing
systematic approaches that examine outcomes of community involvement in health service
planning, implementation, monitoring, and evaluation for a variety of diseases in high and
upper-middle income countries. This review seeks to fill this knowledge gap.
Methods
This review was developed according to PRISMA guidelines (see S1 Table) [11] and submitted
to Prospero at study initiation under record number CRD42016048244. Drawing on the

Box 1. Definitions
Community: Communities are defined as constituted by those with a shared social iden-
tity; that is of members of the same set of social representations, which are the meanings,
symbols, and aspirations through which people make sense of their world.
Community participation: Active group participation or participation of a person as rep-
resentative of the group in activities where they not only provide ideas but are also
involved in the intervention.
definitions by George et al. (2015)[12], the concept of community and community participa-
tion is described in Box 1.
Data sources
We developed the search string in accordance with the underlying objective of the study and
refined it with inputs from an information specialist. The following databases were searched
from January 2000 to September 2016: Medline, Global Health, Embase, Scopus, and LILACs.
The full search terms used for Medline are shown in Table 1.
Inclusion criteria. We included all studies that involved the community, service users,
consumers, households, patients, public and their representatives in the planning, implemen-
tation, monitoring and evaluation of health services, policy, or interventions. These included
studies that involved the community in disease prevention, promotion, or healthy living, and/
or health service delivery. Studies that involved patients in decision making of personal health-
care decisions only were excluded from our review. We also excluded studies where Commu-
nity Based Participatory Research (CBPR) was used merely to suggest ideas rather than as part
of implementation in a community program. For this review, we excluded editorials and theo-
retical studies but included reports which had a description of the community participation
component. We did not impose any language restrictions but limited the search to published
literature from high and upper-middle income countries as defined by the World Bank.
Search and retrieval of studies. Two reviewers (SS and AS) double screened titles and
keywords for 20% of the total articles from the search in the databases (kappa coeffi-
cient = 0.82). The remaining 80% of the articles were distributed among SS and AS and
screened only once due to the high initial Kappa coefficient. Following the title screenings, the
abstracts included were double screened (kappa coefficient = 0.84). Any disagreement at this
stage was discussed between SS and AS. In the absence of a consensus, opinion was sought
from a third reviewer for resolution. Five reviewers (SS, AS, VH, FC, HLQ) conducted the full-
text screening. Articles in languages other than English (e.g. French, German, Spanish, and
Portuguese) were screened by a reviewer who could read and understand the article. Disagree-
ments were resolved by a third reviewer. Only papers that reported outcomes or effects of
community participation were included in this review. The details of the studies screened and
included at each stage are presented in a flowchart in Fig 1.
Data synthesis. Two reviewers (VH and FC) conducted data extraction using standard-
ized forms including categories on: (1) study characteristics including study design and setting,
(2) type of community involvement described in the paper, and (3) outcomes reported. The
two reviewers (VH and FC) met regularly to discuss and resolve any discrepancies or disagree-
ments on the data extraction or interpretation of the studies. We conducted a narrative synthe-
sis of the findings.

Table 1. Medline search string.

Conceptual Areas MeSH terms and free text terms
Community/patient/consumer participation “Community Networks” [MeSH] OR “communit� ” [keyword] “community based
or engagement organizations” [keyword] OR “Community representatives” [keyword] OR
“Community leaders” [keyword]OR “Community health workers” [MeSH] OR
“Community Involvement” [keyword] or “Community-Institutional Relations”
[MeSH] OR “Community based Participatory work” [MeSH] OR “Consumer
participation” [MeSH] OR “community participation” [keyword] OR “Communit�
Involvement” [keyword] OR “Communit� Engag� ” [keyword] OR “community
mobilization” [keyword] OR “Communit� representation” [keyword] OR
“participatory action research” [keyword] or “Social Participation” [MeSH] OR
“Community participants” [keyword] “area participants” [keyword] or “sector
participants” [keyword] or “neighbourhood participants” [keyword] or “citizen
participants” [keyword]
Intervention in planning/ implementation/ “Health Planning” [MeSH] OR “Community Health Planning” [MeSH] OR “supply
monitoring and evaluation chain management” [keyword] OR “Health plan implementation” [MeSH] OR
“Outcome and Process Assessment” [MeSH] OR “Program Evaluation” [MeSH]
OR “program development” [keyword] OR “program monitoring” [keyword] OR
“process monitoring” [keyword] OR “process evaluation” [keyword] OR “Outcome
Assessment (Health Care)” [MeSH] OR “Public Health Practice” OR “Hospital
Planning” [MeSH]
Outcomes/ capacity-building “Capacity Building” [MeSH] OR “Health Policy” [MeSH] OR “Quality of Life”
[MeSH] OR “Health Services Accessibility”[MeSH] OR “Improved health”
[keyword] OR “Delivery of health care” [MeSH] OR “Community health services”
[MeSH] OR ‘Patient Acceptance of Health Care" [MeSH] OR “Patient Satisfaction”
[MeSH] OR “help-seeking” [keyword] OR “power relations” [keyword] OR “power
sharing” [keyword] OR “Attitude to Health” [MeSH] OR “Policy Making” [MeSH]
OR “Health Care reform” [MeSH] OR ‘Health Promotion” [MeSH] OR “Health
Behavior” [MeSH] OR “Health Status” [MeSH] OR “Health Education” [MeSH]
OR “Dissent and Disputes” [keyword]
High income and upper-middle income “Argentina” OR “Albania” OR “Fiji” OR “Namibia” OR “Algeria” OR “Gabon” OR
countries “Palau” OR “American Samoa” OR “Georgia” OR “Panama” OR “Angola”OR
“Grenada” OR “Paraguay” OR “Azerbaijan” OR “Guyana” OR “Peru”OR “Belarus”
OR “Iran” OR “Romania” OR “Belize” OR “Iraq” OR “Russian Federation” OR
“Bosnia and Herzegovina” OR “Jamaica” OR “Serbia” OR “Botswana” OR “Jordan”
OR “South Africa” OR “Brazil” OR “Kazakhstan” OR “St. Lucia” OR “Bulgaria” OR
“Lebanon” OR “St. Vincent and the Grenadines” OR “China” OR “Libya” OR
“Suriname” OR “Colombia’ OR “Macedonia” OR “Thailand” OR ‘Costa Rica” OR
“Malaysia” OR “Turkey” OR “Cuba” OR “Maldives” OR “Turkmenistan” OR
“Dominica” OR “Marshall Islands” OR “Tuvalu” OR “Dominican Republic” OR
“Mauritius” OR “Venezuela” OR “Guinea” OR “Mexico” OR “Ecuador” OR
“Montenegro”OR “Andorra” OR “Gibraltar” OR “Oman” OR “Antigua and
Barbuda” OR “Greece” OR “Poland” OR “Aruba” OR “Greenland” OR “Portugal”
OR “Australia” OR “Guam” OR “Puerto Rico” OR “Austria” OR “Hong Kong” OR
“Qatar” OR “Bahamas” OR “Hungary” OR “San Marino” OR “Bahrain” OR
“Iceland” OR “Saudi Arabia” OR “Barbados” OR “Ireland” OR “Seychelles” OR
“Belgium” OR “Isle of Man” OR “Singapore” OR “Bermuda” OR “Israel” OR “Sint
Maarten” OR “British Virgin Islands” OR “Italy” OR “Slovak Republic” OR
“Brunei” OR “Japan” OR “Slovenia” OR “Canada” OR “Korea” OR “Spain” OR
“Cayman Islands” OR “Kuwait” OR “St. Kitts” OR “Nevis Channel Islands” OR
“Latvia” OR “St. Martin” OR “Chile” OR “Liechtenstein” OR “Sweden” OR
“Croatia” OR “Lithuania” OR “Switzerland” OR “Curacao’ OR “Luxembourg” OR
“Taiwan” OR “Cyprus” OR “Macao” OR “Trinidad and Tobago” OR “Czech
Republic” OR “Malta” OR “Turks and Caicos Islands” OR “Denmark” OR
“Monaco” OR “United Arab Emirates” OR “Estonia” OR “Nauru” OR “United
Kingdom” OR “Faroe Islands” OR “Netherlands” OR “United States” OR “Finland”
OR “New Caledonia” OR “Uruguay” OR “France” OR “New Zealand” OR “Virgin
Islands (U.S.)” OR “French Polynesia” OR “Northern Mariana Islands” OR
“Germany” OR “Norway”OR “High income countr� ” OR “upper-middle income
countr� ” OR “developed countr� ” OR “developed nation� ” OR “developed
population� ”
https://doi.org/10.1371/journal.pone.0216112.t001
Risk of bias assessment. Two reviewers (VH and FC) assessed the studies for risk of bias.
The Cochrane risk of bias tool was used to assess randomized control trials (RCTs) while
observational studies were assessed using a proforma with 3 domains: selection bias, informa-
tion bias, and confounding, then categorised as low, high, or unclear. Qualitative studies were
evaluated for quality with an adapted checklist used in a previous series of mixed methods

Fig 1. PRISMA flowchart.

https://doi.org/10.1371/journal.pone.0216112.g001

systematic reviews [13, 14] scored for ten core criteria. We classified studies with a score of
eight to ten as having an overall low risk of bias, four to seven as having an overall medium
risk of bias, and zero to three as having an overall high risk of bias. We did not conduct a risk
of bias assessment on case studies; however, we have included these studies in our review as
they give insight into the mechanisms of partnerships, inter-organisation collaboration, and
stakeholder satisfaction.
Results
27,232 records were identified through database searching. 23,468 articles were screened by
title followed by 1,740 abstracts screened for inclusion. The full text of 707 articles was
obtained and assessed for eligibility. After screening for reported objectives, 49 articles met eli-
gibility criteria for this review (Fig 1). Due to the heterogeneity in study design, intervention
types, participants, and outcomes, we conducted a narrative synthesis of the findings instead
of a meta-analysis.
Characteristics of included studies

Of the 49 studies that met inclusion criteria, 22 were quantitative, 14 were qualitative, and 13
were case studies. Of the 22 quantitative studies, 6 were RCTs, 8 were intervention studies, 7
were cohort studies, and 1 was a cross-sectional study. The studies could be categorised into
five different disease categories based on the focus of the community participation initiative
described. Of the 49 studies, 16 focused on community health in general, 13 involved initia-
tives that targeted healthy living, 9 focused on non-communicable diseases, 7 studies addressed
infectious diseases, and 4 studies were related to environmental health. The description of each
disease category and the number of relevant studies are presented in Table 2.
Outcome definitions and framework

Reported outcomes were classified as process outcomes, community outcomes, health out-
comes, stakeholder perspectives, and empowerment (See Table 3). We define process out-
comes as short-term outputs that reflect the effectiveness of collaborative processes and
activities over time. Organizational processes are concerned with community-based group
achievements, while community processes are linked to process-related changes in the targeted
community. We define community outcomes as intermediate social effects that represent
changes in community member’s knowledge, attitudes, and behaviors. More extensively, it
Table 2. Categories of community involvement initiatives (n = 49).

Category Description n
Community Health Context specific and priority setting related initiatives for a range of health issues 16
addressed at the community level.
Healthy Living Initiatives focused on nutrition, physical activity and obesity. 13
Non-Communicable Initiatives addressing conditions such as asthma, mental health, diabetes, substance 9
Diseases abuse, etc.
Infectious Diseases Initiatives addressing diseases such as HIV/AIDS, tuberculosis, parasitic diseases, 7
dengue etc.
Environmental Health Initiatives focused on environmental health or natural disaster responses. 4
Overall, studies were located in North America (n = 25), Europe (n = 9), Asia (n = 5), South America (n = 6), Africa
(n = 1), and Oceania (n = 3) (Fig 2). The community health category featured the most geographic diversity with
studies from nine different nations represented. The United States was represented by studies in all categories.

Fig 2. Study location by category.

includes outcomes that reflect impact on social capital, community development, socio-cul-
tural, and environmental improvements. Health outcomes are those that reflect changes in
community member’s health status. We also describe those outcomes that deal with larger
sociopolitical influences, as well as stakeholder perceptions. Studies also report on empower-
ment at the community or individual level, as an outcome. Studies that defined empowerment
framed it as communities coming together to address a self-identified community problem
and create positive change that is self-sustained, contextually appropriate, and fosters knowl-
edge transfer between community members. These studies also point to complicated power
relations and structural differences between community members and professionals or policy
makers that underpin the challenges in defining and measuring community or individual
empowerment (See Table 4).
Outcomes of community involvement initiatives may be viewed through a hierarchy, as
some outcomes necessitate others (See Fig 3); for example in order to deliver a community
involvement program that reports robust health outcomes, it is important to have functional
and sustainable underlying organisational structures, as well as community awareness and

Table 3. Outcomes definitions.

Process Outcomes
Organisational Processes Community Processes Community Outcomes Health Outcomes Perspectives Empowerment
Definition Concerned with the Linked to process- Changes in the Changes in the Stakeholder satisfaction Communities coming
formation, functioning related changes knowledge, attitudes health status of or views with the together to address a self-
and achievements of a identified in the and behaviours of members of the processes of identified community
community-based group targeted community members in the community of community problem and create
or coalition such as increased community on a concern involvement or with positive change that is
community targeted health issue the outputs from those self-sustained,
participation, outreach processes contextually appropriate
or uptake of services and fosters knowledge
transfer between
community members
Example A coalition forms and A community- After an intervention on A healthy living Members of a Members of a community
through the process of academic partnership healthy living in a local intervention leads community academic identify the need for
developing and holds a health fair park, surveyed to decreased BMI coalition report that dengue control and work
implementing a project, where 150 people community members and waist they enjoyed the process together and with local
establishes new or better receive health report a greater circumference pre- of working together and NGOs to implement
working relationships with education, 20 people awareness of the post assessment feel that they have dengue prevention
other community sign up to volunteer importance of physical created a worthwhile measures and community
organisations with the partnership activity and it can be and useful program groups provide dengue
seen by coalition education at churches and
members that the park schools
is used more for jogging
and fitness
involvement. Throughout this hierarchy, both organisation and community members may
report perspectives on the process or outputs and may feel empowered at either a personal or
community level.
The number of outcomes reported by disease category and study design can be found in
Table 5. Twenty-nine studies reported process outcomes, of which twenty-three reported orga-
nisational processes and nine reported community processes; twenty-one studies reported
community outcomes; sixteen reported perspectives of stakeholders on either processes or
project outcomes; six reported on empowerment and twelve reported health outcomes. Pro-
cess outcomes, especially organisational processes, were most often reported in studies involv-
ing community health (n = 12), while both infectious disease and environmental health
category only had one study reporting these outcomes. Empowerment was the least reported
across study categories; of 6 studies, 4 were in the community health category. Health out-
comes were more often reported in healthy living (n = 4) and non-communicable disease ini-
tiatives (n = 5), while community health initiatives reported no health outcomes.
Table 4. Definitions of empowerment reported in studies included.

Definition of Empowerment Category Author/Date
“Individual levels of empowerment" described in terms of youth’s ability to "reach out" and disseminate health Community Ferrera et al 2015 [15]
information to the community. Focus on reaching out to and advocating for undocumented immigrants and Health
helping them to gain confidence, knowledge and access services while "feeling empowered to motivate others to do
the same."
"When local people at all levels are drawn together with the purpose of employing local wisdom to solve a problem Environmental Sansiritaweesook et al
which they all face, the result is a sense of empowerment to make changes, which are intrinsically sensitive to local Health 2015 [16]
circumstances, widely accepted by the community, and because of this, more likely to be sustained"
"Empowerment is related to the process of giving groups of communities autonomy and a progressive and self- Infectious Disease Caprara et al 2015 [17]
sustained improvement of their lives."

Fig 3. Community participation outcomes framework.

Process outcomes
Study characteristics, along with the findings reported, and the risk of bias assessments for
studies that report on process outcomes can be found in Table 6 (See S1 File for table legend
for risk of bias).
Nine studies presented process outcomes relating to contextually appropriate initiatives and
mutually agreeable organizational processes to meet community’s needs [15, 16, 25, 26, 28–30,
44, 45]. Four studies reported on how collaborative processes led to the creation of appropriate
policies and community-led priority setting [19, 22, 34, 43]. Two studies reported clearer role
definition as a process outcome of community involvement in community health initiatives [3,
46] while two studies reported how robust processes enabled the provision of more activities
[20, 47]. Yet, not all partnerships showed favorable results, due to conflicting stakeholder views,
as well as underestimation of the time and resources required for collaboration [35].
Community outcomes
Study characteristics, along with the findings reported and the risk of bias assessments for
studies that report on community outcomes can be found in Table 7 (See S1 File for table leg-
end for risk of bias).
Eight studies provided evidence on community outcomes in the form of increased commu-
nity knowledge and awareness [15, 35, 43, 44, 49, 52, 53, 55]. Two studies involved interven-
tions that focused on community health in general [15, 44], 1 on community mental health
[43], 3 on infectious diseases [35, 52, 55], 1 on environmental health [53], and 1 on a healthy
living intervention involving a physical activity trial [49]. Five studies reported on community
outcomes relating to improved self-efficacy and confidence [22, 27, 46, 52, 54]. Two studies

Table 5. Outcomes by study design and disease category.

Disease Category Study Design Outcomes (n = )
Process Outcomes— Process Outcomes— Community Stakeholder Empowerment Health
Organizational Processes Community Processes Outcomes Perspectives Outcomes
Community Health RCT (n = 1) 1 0 0 0 0 0
Intervention 0 0 0 1 0 0
study (n = 1)
Cohort (n = 3) 1 1 0 1 0 0
Qualitative (n = 7) 6 1 2 4 3 0
Case Study (n = 4) 4 1 1 0 1 0
∑ 12 3 3 6 4 0
Healthy Living RCT (n = 2) 0 0 2 0 0 1
study (n = 3)
Cohort (n = 1) 0 0 1 0 0 1
Cross-sectional 1 0 0 0 0 0
study (n = 1)
Qualitative(n = 3) 1 0 1 2 1 0
Case Study (n = 3) 2 1 1 1 0 0
∑ 5 1 6 4 1 4
Non Communicable RCT (n = 1) 1 0 0 0 0 0
Diseases Intervention 1 0 1 0 0 2
study (n = 2)
Cohort (n = 3) 2 0 0 0 0 2
Qualitative (n = 1) 0 1 0 0 0 0
Case Study (n = 2) 0 1 1 1 0 1
∑ 4 2 2 1 0 5
Infectious Diseases RCT (n = 1) 0 1 1 1 0 1
study (n = 1)
Qualitative (n = 2) 1 0 2 0 0 0
Case Study (n = 3) 0 1 3 2 0 1
∑ 1 3 7 3 0 2
Environmental RCT (n = 1) 0 0 1 0 0 0
Health Intervention 1 0 1 1 0 1
study (n = 1)
Qualitative(n = 1) 0 0 0 1 0 0
Case Study (n = 1) 0 0 1 0 1 0
∑ 1 0 3 2 1 1
∑ 23 9 21 16 6 12
that reported on such outcomes had contextually tailored interventions on HIV and AIDS [52,
54]. Both studies reported positive impact on its target population including increased confi-
dence and personal development among peer educators and sex workers, decreased HIV
stigma, reduced proportion of men reporting that they had engaged in unprotected sex, and
increased positive attitudes in condom use.
Stakeholder perspectives
studies that report on stakeholder perspectives can be found in Table 8 (See S1 File for table
legend for risk of bias).

Table 6. Study characteristics, findings reported and the risk of bias assessments for studies that report on process outcomes (n = 28).
Study Country Study Design Sample Disease Category Type of Type of Relevant Findings Risk of bias
Community Involvement Outcome
s p d a r Overall
Gloppen et al 2012 United RCT 12 pairs of matched Community Communities That Care (CTC) coalitions—mobilize stakeholders to Process 20 months after study support ended which included tailored training, technical assistance, and funding: 1) 11 of the 12 CTC Medium
[18] States communities in 7 states Health implement prevention programs to promote adolescent health and wellbeing. Outcome coalitions still existed. 2) CTC coalitions maintained a relatively high level of implementation fidelity to the CTC system.
Boivin et al Canada RCT 172 individuals from 6 Non Communities involved to set priorities for improving chronic disease Process 1) Priorities established with patients were more aligned with components of the Medical Home and Chronic Care Model Low
2014 [19] communities Communicable management in primary care. Outcome (p < 0.01). 2) Priorities established by professionals alone placed more emphasis on technical quality of disease management. 3)
Disease 41% increase in agreement on common priorities (95%CI: +12% to +58%, p < 0.01). 4) Patient involvement increased the costs of
the prioritization process by 17%, and required 10% more time to reach consensus on common priorities.
s p d a r Overall
Sansiritaweesook Thailand Intervention 182 informants, 562 surveillance Environmental 7-step process used to develop a model for local drowning surveillance system Process 1) Villagers collaborated to conduct a situation analysis, design, and trial a prototype intervention, scale up to a full system design Medium
et al 2015 [16] study networks, 21,234 villagers Health based on community participation. Outcome and trial that was followed by system improvement and dissemination. 2) 80% of networks were cooperative in submitting timely
reports and using them for action. 3) Accuracy of information in reports increased from 65% to 90%.
Hoelscher et al 2010 United Intervention 15 schools receive BPC Healthy Living School-based obesity prevention program (CATCH BP) versus complimentary Process 1) BPC schools demonstrated better outcomes with more activities and lessons than BP schools. 2) In year 2 there was a higher Unclear
[20] States study intervention, matched with 15 program (CATCH BPC) that formed partnerships with external community Outcome mean number of physical activity and healthy eating programs being implemented in BPC schools (mean = 3.71 programs)
schools that receive BP only organizations. compared to BP schools (mean = 2.73 programs).
Neto et al 2003 [21] Brazil Intervention 1,524 households in intervention Infectious Disease A preliminary diagnosis presented to the community to launch a discussion Process Changes in the study area included: vector control workers began demonstrating preventive measures without removing potential Unclear
Study area; 1,564 households in control aimed at defining future actions, implementation of the actions in the study Outcome breeding places or using larvicide; use of educational aids specific to the local reality; activities related to the residents’ priorities;
area area with community participation. and activities such as music, theater skits, scavenger hunts, and games to demonstrate the vector cycle.
Clark et al United Intervention 1,477 parents of children with Non Allies Against Asthma program—a 5-year collaborative effort by 7 community Process 89 inter- and intra-institutional changes were made on systems and policies to statewide legislation across the 7 communities. Unclear
2014 [22] States study asthma in coalition target areas Communicable coalitions designed to change policies regarding asthma management in low- Outcome
and comparison areas Disease income communities of color.
s d n c Overall
Nathan et al Australia Cohort 47 staff in 2001; 43 in 2002 Community Community Representatives Program—community members provided the Process 1) Significantly more staff at the follow-up survey reported that they and other staff were clear about the role of community Unclear
2006 [23] Health opportunity to give input on service delivery issues and needs in the Outcome representatives and how to work with them on committees. 2) Significantly more staff at follow-up felt that the health service was
community and to be active participants in committee work of the health ready for this type of initiative.
service through participation in decision-making committees with other
stakeholders.
Akiyama et al 2013 Thailand Cohort 43 primary-level schools Community Health Promoting School program with the aim of encouraging schools to Process 1) Increase in school and community partnership [mean score 1.0 pre (median = 1.0, IQR = 0.5–1.5) vs. 2.4 post (median = 2.5, Medium
[24] Health improve school health. Interventions include 6 one-day training workshops Outcome IQR = 2.0–3.0)]. 2) Improvements in the definition of the roles and responsibilities with the Burmese community [mean score 0.4
and an action plan support involving teachers. pre (median = 0, IQR = 0) vs. 2.7 post (median = 3.0, IQR = 3.0–3.0)].
Reeve et al Australia Cohort N/A Non A health service partnership between an Aboriginal community-controlled Process Short-term outcomes– 1) Increase in occasions of service (from 21,218 to 33,753) particularly in PHC in remote areas (from 863 to Medium
2015 [25] Communicable health service, a hospital, and a community health service that implemented an Outcome 11,338). 2) Increased uptake of health assessment (from 13% of eligible population to 61%, then to 73% of those identifies with DM
Diseases integration of health promotion, health assessments, and chronic disease placed on a care plan). Medium-term outcomes– 1) Over a 6 year period, improvements in quality-of-care indicators, i.e. glycated
management. hemoglobin checks and proportion of people with DM receiving anti hypertensives. 2) Increase in proportion of patients
identified with chronic disease or risk factors. 3) Increased PHC episodes and follow-up.
PLOS ONE | https://doi.org/10.1371/journal.pone.0216112 May 10, 2019

Nelson et al Canada Cohort 79 Consumer Non Consumer Survivor Initiatives—organizations that are operated by and for Process Members participated most often in internal activities (e.g. social-recreational, committees) and least often in external activities Low
2006 [26] Survivor Initiative members Communicable people with a history of mental illness. Outcome (e.g. advocacy, planning, education) with an average of 3 activities per month.
Diseases
Litt et al United Cross- 59 collaborative groups Healthy Living Collaboratives formed to improve the built environment and policies for active Process Groups made progress in identifying areas for environmental improvements and in many instances received funding to support High
2013 [27] States sectional representing 22 states living. Outcome these changes: 1) Groups’ environmental improvement scores ranged from 1.5 to 5.0, with an average of 3.5 (SD: 0.9). This average
indicated that groups typically had funding to support their initiatives and had started but had not completed the planned
improvements. 2) Groups’ policy change scores ranged from 1.0 to 4.5 with an average of 2.9 (SD: 1.0), suggesting that groups had
generally identified a policy gap and had started discussions to develop new policies or changes to existing policy.
1 2 3 4 5 6 7 8 9 Overall
Gibbons et al 2016 United Qualitative 3 focus groups, 8 in-depth Community Community-academic collaboration using CBPR known as the ’Community Process 1) Enabled the development of authentic community-academic relationships. 2) Enabled N Y Y Y Y N Y N N N Medium (5/
[28] States interviews, 31 individuals Health Health Initiative: Creating a Healthier East Baltimore Together.’ Outcome establishment of a “level playing field” among residents. 3) Enabled change in attitudes, 10)
surveyed perceptions among personnel and residents of each other. 4) Enabled residents to become
active participants of the decision-making process.
Trettin et al United Qualitative 6 to 14 participants of 3 focus Community Volunteer-based community health advisory program developed to increase Process 1) Planning approach for the program identified as appropriate for local context. 2) Existing N Y Y Y Y Y Y N N Y Medium (7/
2000 [29] States groups (total n = 60) Health residents’ access to health services, stimulate their interest in health, disease Outcome list of problems and needs identified as accurate with perspectives of local participants. 3) 10)
prevention, and awareness of health-related environmental issues, and Field-workers established good relationships with the community.
empower residents to be more involved in community health.
Carlisle et al United Qualitative Not mentioned. Semi-structured Community ’Social Inclusion Partnerships’—organized around committee-style Process Drug and alcohol misuse classified as a particular problem amongst younger people. Y N Y N Y N N N N N High (3/10)
2010 [30] Kingdom interviews Health management board meetings attended by members from statutory, voluntary, Outcome
and community sectors.
Johnson et al 2006 United Qualitative 40 community based Community CBOs involved in implementing health-related projects through locally Process Microfinancing CBOs aided in: 1) Building partnerships and connections within and outside N Y Y Y Y Y Y N N Y Medium (7/
[31] States organizations (CBOs) selected Health administered micro-grants. ’The Healthy Carolinians Community’ serving as Outcome their communities. 2) Gained new ideas and knowledge. 3) Developed local leadership and 10)
for interview grantors partnering with the CBOs expertise. 4) Increased their ability to focus on and progress towards goals.
Ferrera et al 2014 United Qualitative 23 youths interviewed Community CBPR used to form a Youth advisory board. Youth involved in decision Process 1) Students feel consistently comfortable with program staff and the sense that a personal and Y Y Y Y Y N N N N Y Medium (6/
[15] States Health making and programming, as well as in a feedback and improvement role. Outcome emotional investment was made. 2) Program participants went on to give health education to 10)
approximately 800 community members. 3) 500 community members attended the health fair
hosted by a participating school.
Heaton et al 2014 United Qualitative Interviews, focus groups Community Collaborative partnership between 2 academic health centers and CBOs to Process 1) Partnership had good adherence to principles of collaborative and equitable group process N Y Y Y Y Y Y Y N Y Low (8/10)
[32] States Health determine topics, and develop a bi-directional educational seminar series Outcome in planning of the CGR event. 2) Educational seminars facilitated bi-directional
called ’Community Grand Rounds’ (CGR). communication between their community and university medical center. 3) Format and
content of seminars effectively tailored to unique needs of each community.
Litt et al 2013 [33] United Qualitative 59 participants from Healthy Living Multi-sectoral collaborative groups promote active lifestyles through Process 1) Groups reported working on an average of 5 strategy areas including parks and recreation N Y N N N N N N N N High (1/10)
States collaboratives interviewed environmental and policy changes. Outcomes (86%), Safe Routes to School (85%), street improvements (78%) and streetscaping (69%). 2)
More than half of groups reported their environmental initiatives as either in progress or
completed. 3) Groups reported the most success in changing policy for public plazas, street
improvements, streetscaping, and parks, open space, and recreation.
Rutter et al 2004 [34] United Qualitative 32 interviews conducted in one Non User or patient involvement in the planning and delivery of health services Process Positive outcomes of user involvement reflected in their participation in campaigns against N Y Y Y Y N Y N N N Medium (5/
Kingdom trust and 17 interviews in Communicable through meetings between service managers and users; development of Outcomes Trust plans; in refurbishing of inpatient units; in contract specification and monitoring of hotel 10)
another trust of service users and Diseases documents by user groups; service provider (Trust) meetings involving user services; in policy, practice and information about women’s safety; and in integration of health
sector reps representation. and social services.
(Continued)
11 / 25
Table 6. (Continued)
Chervin et al 2005 United Qualitative 364 in-person interviews with Infectious Center for Disease Control and Prevention’s Community Coalition Process 1) Partners worked together to reduce duplication and fill gaps in services through N Y Y Y Y Y Y N N N Medium (6/
[35] States project staff, evaluators, and Diseases Partnership Program–building a community’s capacity to prevent teen Outcome collaboration and differentiation of activities. 2) Development of new programs from the 10)
community and agency pregnancy through strengthening of partnerships, mobilization of community partnership. It was noted however that increased partner skill, program improvements, and
members resources, and changes in the number and quality of community programs. new programs did not appear sufficient to affect community capacity.
Study Country Study Design Sample Disease Category Type of Type of Relevant Findings Risk of Bias
von dem Knesebeck Germany Case Study Not mentioned Community A community-level health policy intervention: ’Local Co-ordination of Health Process 1) 70% agreement between managers of Project Offices, moderators and other key actors on usefulness of ’Round Table’ to improve coordination of N/A
et al 2002 [36] Health and Social Care’ project. Outcome health and social care at the community level. 2) Success in the development and enactment of recommendations for action programs e.g. improved
information dissemination, further development of geriatric ambulatory rehabilitation. 3) Development of health monitoring and reporting activities at
the community level. 4) Improved cooperation among participating communities through increased transparency.
Keene Woods et al United Case Study Not mentioned Community Community Change Intervention that focused on building coalition capacity Process 1) Coalition facilitated an average of at least 3 times as many community changes (i.e., program, policy, and practice changes) per month following the N/A
2014 [37] States Health to support implementation of community changes for program, policy, and Outcome intervention. 2) After intervention, there was increased implementation of 3 key prioritized coalition processes: Documenting progress/using feedback
practice. (75% increase in stakeholders involved in designing the documentation system); making outcomes matter (50 to 100% increase in activities relating to
incentives, accountability, and use of longer term outcomes with accountability); and sustaining the work (42% to 75% increase in identification of
sustainability decision makers, determining what to sustain and duration of sustained effort). 2) A 1-year probe following the study showed that majority
of the community changes were sustained.
Bursztyn et al 2008 Brazil Case Study Not mentioned Community A project was developed and implemented in primary health centers to Process 1) Self-assessment workshops were held with the local teams. Despite good awareness among the health professionals, the project’s results varied between N/A
[38] Health improve young men’s adherence to a teenage health care program using Outcome health centers. Over-centralization and lack of flexibility appear to be related to lower capacity to incorporate new practices. 2) Health centers where
participatory planning techniques, and rapid assessment procedures. specific strategies were observed showed more successful results.
Orozco-Núñez et al Mexico Case Study Not mentioned Community Use of participative strategies and the creation of support networks for poor Process Coordination and community participation were relevant in relation to major resources allocation and availability, particularly housing and N/A
2009 [39] Health pregnant women. Outcome transportation.
Baker et al United Case Study Not mentioned Healthy Living ’Active Living by Design’ partnerships were established to change Process The connections among diverse community partners created a foundation that enhanced lead agency efforts to form, implement, and maintain policy N/A
2012 [40] States environments and policies, and support complementary programs and Outcome changes and physical projects, as well as promotional and programmatic approaches, to support active living.
promotions to increase physical activity.
Rapport et al 2008 United Case Study Focus groups with project Healthy Living Action research project–organized to respond to a context of funding and Process 1) Community members involved acquired new skills and "strengthened individual competencies," heightened knowledge amongst the community and N/A
[41] Kingdom steering group service delivery, helmed by a Project Steering Group made up of community Outcome Project Steering Group of community members’ needs and desires," influenced working practices, altered perspectives and raised awareness of issues
members, study organizers, statutory board members. surrounding trust and communication within partnerships. 2) The data generated by the community interviews was perceived as more robust evidence
that could be "taken seriously and gave credibility to the communities’ comments and requests."
Diaz et al 2009 [42] Cuba Case Study Not mentioned Infectious Ecohealth approach used as a strategy to ensure active participation by the Process 1) The strategy had been sustained two years after concluding the process. 2) 93.5% had attended trainings under the project and 89% knew that the N/A
Diseases community, diverse sectors, and government. The approach allowed holistic Outcome inhabitants of the neighborhood had organized themselves into groups promoted by the project. 3) 93.5% considered that the community improved its
problem analysis, priority setting, and administration of solutions. ability to identify problems that affected its ecosystem and proposed solutions.
Barnes et al United Case Study Not mentioned Non Users of a community mental health inter-professional training program Process Commitment to partnership established, reinforced by service users participating in the commissioning of the program and its evaluation, e.g. service N/A
2006 [43] Kingdom Communicable (partnerships with service users) involved in the commissioning, management, Outcome users took active part in the steering group that advised research.
Diseases delivery, participation, and evaluation of the program, as trainers and as
course members.

12 / 25
Table 7. Study characteristics, findings reported and the risk of bias assessments for studies that report on community outcomes (n = 20).
s p d a r Overall
Ardalan et al Iran RCT 15 intervention villages and 16 Environmental Intervention assembles Village Disaster Taskforces (VDTs), conducts Community 1) Adjusted odds ratio for participation in an evacuation drill in intervention Medium
2010 [48] control villages Health training of VDTs and community, evacuation drills, and program Outcome area post vs. pre-assessment was 29.05 (CI: 21.77–38.76) compared to control
monitoring. area 2.69 (CI: 1.96–3.70) (p<0.001). 2) Participation in a family preparedness
meeting and risk mapping were helpful in motivating individuals to take
preparedness actions.
Solomon et al 2014 United RCT (Stepped 10,412 adults Healthy Living Intervention developed with local partners using local knowledge and Community Low penetration of intervention wherein 16% of intervention participants High
[49] Kingdom wedge cluster) (intervention = 4693; resources to facilitate local involvement in planning, promotion, and Outcome reported awareness of intervention and 4% reported participating in
control = 5719) delivery of a physical activity intervention. intervention events.
Derose et al United RCT 33 intervention parks (2 Healthy Living CBPR approaches used to increase park use and physical activity Community Intervention parks invested in new and diversified signage, promotional High
2014 [50] States interventions, 17 control parks across 33 neighborhoods. Outcome items, outreach or support for group activities like fitness classes and walking
clubs, and various marketing strategies; working with departmental
management established structures for community input and park policy
facilitated implementation and sustainability.
Caprara et al Brazil RCT 10 intervention clusters, 10 Infectious Disease Intervention adopted an Ecohealth approach to involve community Community Increase in peoples’ knowledge of dengue and willingness to participate in Low
2015 [17] control clusters through workshops, clean up campaigns, mobilization of school Outcome preventive actions.
children and seniors, and distribution of information, education, and
communication materials.
s p d a r Overall
Sansiritaweesook Thailand Intervention 182 informants, 562 surveillance Environmental 7-step process used to develop a model for local drowning surveillance Community Additional drowning prevention and rescue devices made available at high Medium
et al 2015 [16] study networks, 21,234 villagers Health system based on community participation. Outcome risk water resources. Proportion of sites with devices increased from 18.4% to
83.7%. Sites with security measures increased from 13.2% to 76.7%. Level of
surveillance at high risk sites rose from 88.4% to 100%. Children 7–15 years
who could swim rose from 38.5% to 52% following swimming lessons.
Training of rescue volunteers in CPR increased from 6% to 27.4%. Proportion
of village health workers trained in CPR increased from 12.7% to 87.9%.
Yajima et al Japan Intervention 20 participants each from 13 Healthy Living Health promotion program consisting of a community leaders Community Intervention group pursued healthier lifestyles than the comparison Unclear
2001 [51] study municipalities (intervention committee trained to conduct health promotion activities. Outcome group. 22% of the Intervention group and 4% of the comparison group
group), 2000 in reference group frequently obtained information from health professionals. 29.8% of the
intervention group and 10.8% of the comparison group were satisfied with
their access to health-related information. Significantly more people in the
Intervention group were doing exercise, eating meals regularly, paying
attention to nutritional balance and to food additives, were interested in
health, and were satisfied with access to health information after excluding the
effects of age and socio-economic factors (p<0.05). People in the intervention
group were significantly more likely to have greater health literacy regardless
of socio-economic status.
Neto et al 2003 [21] Brazil Intervention 1,524 households in intervention Infectious Disease A preliminary diagnosis presented to the community to launch a Community Potential domiciliary breeding sites were significantly reduced; the proportion Unclear
Study area; 1,564 households in control discussion aimed at defining future actions, implementation of the Outcome of houses without breeding sites was significantly increased; and there was an
area actions in the study area with community participation. increase in the percentage of individuals who recognized the larval form of the
vector in the study area as compared to the control area.
Clark et al United Intervention 1,477 parents of children with Non Allies Against Asthma program—a 5-year collaborative effort by 7 Community Allies parents, significantly more so than the comparison group parents, felt Unclear
2014 [22] States study asthma in coalition target areas Communicable community coalitions designed to change policies regarding asthma Outcome less helpless or frightened when confronted by a symptom episode (mean
and comparison areas Disease management in low-income communities of color. score change: 0.30 vs. 0.75; p = 0.014) and less angry about their child’s
asthma (mean score change: 0.16 vs. 0.57; p = 0.011). Allies parents exhibited
a greater increase in concern than did comparison parents about medications
and side effects (mean score change: 1.22 vs. 0.79; p = 0.022), indicating
higher awareness.
s d n c Overall
Davison et al United Cohort 423 children age 2–5 Healthy Living CBPR used to develop and pilot test a family-centered intervention for Community Parents at post intervention reported significantly greater self-efficacy to Low
2013 [46] States low-income families with preschool-aged children. Outcome promote healthy eating in children and increased support for children’s
physical activity. Dose effects observed for most outcomes.
1 2 3 4 5 6 7 8 9 Overall
Ferrera et al United Qualitative 23 youths interviewed Community CBPR used to form Youth advisory board and youth involved in Community Greater knowledge of health issues and the Y Y Y Y Y N N N N Y Medium (6/
2014 [15] States Health decision making and programming, as well as in a feedback and Outcome importance of screening. 10)
improvement role.
Heaton et al United Qualitative Interviews, focus groups Community Collaborative partnership between 2 academic health centers and Community Increased knowledge and awareness on N Y Y Y Y Y Y Y N Y Low (8/10)
2014 [32] States Health CBOs to determine topics, and develop a bi-directional educational Outcome health and social issues among
seminar series called ’Community Grand Rounds’. community; Improved trust between
academic partners, and community.
Litt et al United Qualitative 59 participants from Healthy Living Multi-sectoral collaborative groups promote active lifestyles through Community Most groups achieved some form of N Y N N N N N N N N High (1/10)
2013 [33] States collaboratives interviewed environmental and policy changes Outcomes environmental or policy change.
Campbell et al 2001 South Qualitative 30 members of community Infectious A community-based peer education program led by sex workers as an Community Increased confidence and personal Y Y Y Y N N Y N Y Y Medium (7/
[52] Africa interviewed Diseases initiative in grassroots participation in sexual health promotion. Outcomes development among peer educators and 10)
increased confidence among some sex
workers.
Chervin et al United Qualitative 364 in-person interviews with Infectious Centers for Disease Control and Prevention’s Community Coalition Community 1. Increased community awareness of the N Y Y Y Y Y Y N N N Medium (6/
2005 [35] States project staff, evaluators, and Diseases Partnership Program (CCPP)—building a community’s capacity to Outcome problem of teen pregnancy and 10)
community and agency members prevent teen pregnancy through strengthening of partnerships, willingness to discuss the issue; 2.
mobilization of community resources, and changes in the number and Improved knowledge and skills relating to
quality of community programs. addressing teen pregnancy.
Orozco-Núñez et al Mexico Case Study Not mentioned Community Use of participative strategies and the creation of support networks for Community Governmental actors’ involvement and leadership favored linking and coordination. Authorities, N/A
2009 [39] Health poor pregnant women. Outcome relatives, volunteers and users supported the referrals for obstetric emergencies, the identification of
pregnant women in isolated areas, and their referral to health services. Around one-third of the users
indicated geographical, economic, and cultural access barriers to health services in the four states,
particularly those living in rural areas. Even though most of the informants received timely attention
with a favorable evaluation of the treatment received in the units, testimonies were collected from
users reporting feeling abused by transporters and suppliers.
Setti et al 2010 [53] Brazil Case Study 24 participants Environmental The Neighborhood Ecological Program that involved the participation Community The program is reported to promote empowerment and community strengthening, dissemination of N/A
Health and empowerment of citizens in health promotion and sustainable Outcome information and knowledge, development of critical thinking, and the creation of support networks.
development
(Continued )

Barnes et al United Case Study Not mentioned Non Users of a community mental health inter-professional training Community 1) Increase in mean of ’knowledge of factors involved in facilitating therapeutic cooperation’ [5.8 (2.2 N/A
2006 [43] Kingdom Communicable program (partnerships with service users) involved in the Outcome SD) vs. 8.3 (1.2 SD), p<0.001]. 2) Increase in mean of ’skills in facilitating therapeutic cooperation’
Diseases commissioning, management, delivery, participation, and evaluation [5.9 (2.3 SD) vs. 8.2 (1.3 SD), p<0.001]. 3) Increased in mean of ’A user-and carer- oriented
of the program, as trainers and as course members. perspective based on partnership in the provision of assessment, treatment and continuing care’ [6.0
(2.1 SD vs. 8.5 (1.2 SD), p<0.001)]. 4) Increased knowledge on learning where and how to access
information, developing directories of local service user groups/resources, and understanding the
value of advocacy. 5) Positive changes in attitudes towards partnership with service users. 6) Positive
changes in behavior at individual level, e.g. students more conscious of sharing decision-making and
using a needs-led approach following awareness of the imbalance of power between service users and
professionals. 7) Positive changes in behavior at organizational level, e.g. the setting up of service user
groups, ensuring user views are fed into planning decisions, supporting service users on staff
recruitment panels, writing leaflets for users/carers about services offered, and collating info on
resources for users.
Wilson et al United Case Study 71 participants Infectious CBPR used to develop the Barbershop Talk With Brothers (BTWB) Community 1) Proportion of men who reported not having engaged in unprotected sex in past 3 months N/A
2014 [54] States Diseases program—a community-based HIV prevention program that seeks to Outcome increased from baseline to follow-up administration of survey (25% to 41%, p = 0.007). 2) Proportion
improve individual skills and motivation to decrease sexual risk, and of men who reported having unprotected sex with two or more women in the past 3 months declined
that builds men’s interest in and capacity for improving their (46% to 17%, p = 0.0001). 3) Proportion of men reporting favorable attitudes towards condoms and
community’s health. confidence in their self-efficacy to use condoms consistently increased (p<0.05). 4) HIV stigma
decreased, but difference did not reach statistical significance (Mean = 24.7; SD = 8.4 to Mean = 22.8;
SD = 8.8; p = 0.11).
Diaz et al 2009 [42] Cuba Case Study Not mentioned Infectious Ecohealth approach used as a strategy to ensure active participation by Community At the outset, 85% of the outbreaks of the dengue vector were in tanks located in the patios of the N/A
Diseases the community, diverse sectors, and government. The approach Outcome houses. Two years later only 29% were located in the patios. Currently, no outbreaks have been
allowed holistic problem analysis, priority setting, and administration identified in the deposits located in the houses. It was found that 16% of the 4,878 courtyards in the
of solutions. territory were unhealthy. Two years after the end of the study, these constituted less than 1%; The
number of unprotected tanks decreased from 62% to 8% (n = 4,678).
King et al American Case Study 50 representatives from churches Infectious Disease Modified the initial Mass Drug Administration (MDA) strategy and Community 261 detailed surveys– 95.4% had heard of filariasis and increase (x2 = 19.2; p<0.001) from the 2003 N/A
2011 [55] Samoa interviewed partnered with various community groups including church groups Outcome KAP survey. Among those heard of filariasis 91.2% knew what it was an increase (x2 = 20.1; p<0.001)
for drug distribution, dissemination of messages about prevention of from 2003.
filariasis, and to encourage compliance. Developed radio and
television ads to encourage "pill taking" and advertising locations of
distribution.
In five studies, participants reported positive experiences or satisfaction with the community
participatory initiative [15, 58, 59, 61, 62], three of which involved community-academic partner-
ships [58, 61, 62]. Six studies reported on stakeholder perspectives that reflected positive
Table 8. Study characteristics, findings reported and the risk of bias assessments for studies that report on stakeholder perspectives.
s p d a r Overall
Abbema The Intervention 5000 residents in Community Intervention ’Arnhemse Broek, Healthy and Wellbeing’— Stakeholder No significant effects on improved perceived health or health-related problems were found at the High
et al 2004 Netherlands study experimental areas, 7000 Health direct involvement of community members during center Perspectives residents-level, and the problems identified. Results failed to prove effectiveness of the community
[56] and 9500 in 2 control visits for health priorities setting. intervention.
areas
s d n c Overall
Cargo et al Canada Cohort 28 at T1, 44 at T2, 51 at Community University-Aboriginal community partnership for research. Stakeholder 1) Increased ownership of community program staff was perceived as primary owner at T1 and shared Medium
2011 [57] T3 (representatives from Health Perspectives ownership with Community Advisory Board members at T2 and T3. 2) Trend tests indicated greater
partners) perceived ownership between T1 and T3 for CAB (p < .0001) and declining program staff (p < .001)
ownership over time. 3) Academic partners were never perceived as primary owners.
1 2 3 4 5 6 7 8 9 Overall
Ndirangu United Qualitative 2 focus groups with 2 to 8 Community Community-academic partnership. Members included a Stakeholder 1) Participants expressed satisfaction with the formation and Y Y Y Y Y Y Y N N Y Low (8/10)
et al 2008 States participants each from Health non-profit agency, university representatives, and Perspectives maintenance of the committees and noted that the committees were
[58] each of 3 communities participants from health, education, government, and lay still actively meeting in the community 2 years after they were
leadership sectors. formed. 2) Satisfaction with committee participation in community
events. 3) Satisfaction with raising awareness about the committee in
the community. 4) Participants spoke of individual benefits of
becoming personally more aware of nutrition and physical activities.
Ferrera et al United Qualitative 23 youths interviewed Community CBPR used to form youth advisory board and youth Stakeholder 1) All youths (n = 23) had positive experiences with the program and Y Y Y Y Y N N N N Y Medium (6/
2014 [15] States Health involved in decision making and programming, as well as in Perspectives believe it should be expanded to other schools. 10)
a feedback and improvement role.
Heaton et al United Qualitative Interviews, focus groups Community Collaborative partnership between 2 academic health centers Stakeholder 1) Good satisfaction with ’contract model’ used to solidify partnership N Y Y Y Y Y Y Y N Y High (8/10)
2014 [32] States Health and CBOs to determine topics, and develop a bi-directional Perspectives and lay out expectations. 2) CGR program met/exceeded their
educational seminar series called ’Community Grand expectations.
Rounds’ (CGR).
Derges et al United Qualitative 61 individuals Healthy Living Community Engagement Model—Well London program, Stakeholder 1) Positive benefits reported by those who participated in project N Y N Y Y Y Y N N Y Medium (6/
2014 [59] Kingdom interviewed community specific interventions for healthy eating, Perspectives activities. 2) Extent of benefits experienced was influenced by physical 10)
physical activity, and mental wellbeing delivered in and social factors of each neighborhood. 3) Highest level of change in
socioeconomically deprived neighborhoods. perception occurred in neighborhoods where there was social
cohesion, personal and collective agency, and involvement and
support of external organizations.
Kennedy United Qualitative 35 key informants Healthy Living ‘Lay food and health workers’ and professionals involved in Stakeholder 1) Salient benefits identified were increased service coverage, ability to Y Y Y Y Y Y Y N Y Y Low (9/10)
et al 2010 Kingdom interviewed delivering local food and health initiatives in less-affluent Perspectives reach the "hard to reach", as well as personal development and
[60] neighborhoods. enhanced social support.
Mason et al United Case Study 10 parks Healthy Living A CBPR evaluation engaged community and academic Stakeholder 1) Staff (100%) and patrons (88%) reacted positively to the initiative. 2) Patrons overwhelmingly approved of the more healthful N/A
2014 [61] States partners done to evaluate the acceptability, sales impact, and Perspectives snack vending items—88% reported liking the snack vending items they tried, 98% indicated that would purchase the snacks
implementation barriers for the Chicago Park District’s again. 3) Sales exceeded the expectations of both district staff and vendors. Average monthly sales volume per machine also
100% Healthier Snack Vending Initiative aimed at exceeded industry sales estimates of $300 per month for snack vending machines located in “average” locations, which typically
strengthening healthful vending efforts. have 10 sales per day.
Basu Roy United Case Study 69 participants Non Queens Library HealthLink program, a CBPR academic– Stakeholder 1) 78% of 69 survey participants agreed that community interests are well represented in council projects. 2) 97% agreed that N/A
et al 2014 States interviewed, 4 focus Communicable community partnership, aimed to reduce cancer disparities Perspectives council members have a voice in the development of programs. 3) 97% acquired useful knowledge about programs, services, or
[62] groups Diseases through neighborhood groups, Cancer Action Councils that people in the community. 4) 94% developed valuable relationships. 5) 94% reported increased ability to contribute to
convened in public libraries. communities. 6) 91% felt they made a greater impact than they would have on their own. 7) 88% developed an enhanced ability
to address an important issue. 8) Participants reported accomplishments in planning and hosting of events, cancer screenings,
and conducting health fairs.

Table 9. Study characteristics, findings reported and the risk of bias assessments for studies that report on empowerment (n = 7).
Study Country Study Sample Disease Type of Type of Relevant Findings Risk of bias
Design Category Community Involvement Outcome 1 2 3 4 5 6 7 8 9 Overall
Gibbons United Qualitative 3 focus groups, Community Community-academic Empowerment Community participation led to N Y Y Y Y N Y N N N Medium
et al 2016 States 8 in-depth Health collaboration ’Community empowerment of residents, (5/10)
[28] interviews, 31 Health Initiative: Creating a through skills based training as
individuals Healthier East Baltimore part of the asset mapping
surveyed Together’ using CBPR. research process.
Trettin United Qualitative 6 to 14 Community Volunteer-based community Empowerment Sense of empowerment fostered N Y Y Y Y Y Y N N Y Medium
et al 2000 States participants of 3 Health health advisory program among participants when they (7/10)
[29] focus groups developed to increase residents’ were given greater control over
(total n = 60) access to health services, the direction of the program.
stimulate their interest in health,
disease prevention, and
awareness of health-related
environmental issues, and
empower residents to be more
involved in community health.
Ferrera United Qualitative 23 youths Community CBPR used to form youth Empowerment Improved sense of agency Y Y Y Y Y N N N N Y Medium
et al 2014 States interviewed Health advisory board and youth amongst students. Community (6/10)
[15] involved in decision making and participation facilitated an
programming, as well as in a understanding of how students
feedback and improvement role. may have a positive impact on
their community. "Individual
levels of empowerment"
described in terms of youth’s
ability to "reach out" and
disseminate health information
to their family members and the
immigrant community.
Reaching out to and advocating
for undocumented immigrants
helped them to gain confidence
and knowledge on accessing
services. They felt empowered to
motivate others to do the same.
Kennedy United Qualitative 35 key Healthy Living ‘Lay food and health workers’ Empowerment Empowerment was perceived as Y Y Y Y Y Y Y N Y Y Low (9/
et al 2010 Kingdom informants and professionals involved in both an individual benefit and a 10)
[60] interviewed delivering local food and health benefit to the community
initiatives in less-affluent resulting from the program.
neighborhoods.
Study Country Study Sample Disease Type of Type of Relevant Findings Risk of
Design Category Community Involvement Outcome Bias
Setti et al Brazil Case Study 24 participants Environmental The Neighborhood Ecological Empowerment Participation in the implementation of the program favored empowerment N/A
2010 [53] Health Program that involved the among individuals and groups.
participation and empowerment
of citizens in health promotion
and sustainable development.
Wilson United Case Study 71 participants Infectious CBPR used to develop the Empowerment Increased perceptions of community empowerment (Mean = 18.7; SD = 4.0 N/A
et al 2014 States Diseases ‘Barbershop Talk With Brothers’ to Mean = 19.6; SD = 3.4; p = 0.06).
[54] program—a community-based
HIV prevention program that
seeks to improve individual skills
and motivation to decrease
sexual risk, and that builds men’s
interest in and capacity for
improving their community’s
health.
Diaz et al Cuba Case Study Not mentioned Infectious Ecohealth approach used as a Empowerment Community was strengthened and empowered by creating neighborhood N/A
2009 [42] Diseases strategy to ensure active groups, and by developing communication skills to work in such programme.
participation by the community,
diverse sectors, and government.
The approach allowed holistic
problem analysis, priority
setting, and administration of
solutions.
community-level outcomes [57–59, 61–63]. Two of these studies reported greater awareness of the
targeted health issue or services among the community, both of which involved community-aca-
demic partnerships [59, 62]. Three studies reported perceptions relating to the processes of involv-
ing the community, although results were mixed [44, 57, 58]. Two of the studies reported
stakeholder satisfaction with service coverage, staff development, enhanced networks, and creation
of new alliances [44, 58]. However, another qualitative study that investigated perspectives of a

Table 10. Study characteristics, findings reported and the risk of bias assessments for studies that report on health outcomes (n = 12).
s p d a r Overall
Solomon et al 2014 United RCT (Stepped 10,412 adults Healthy Living Intervention developed with local partners using Health 1) Intervention did not increase the odds of adults High
[49] Kingdom wedge cluster) (intervention = 4693; local knowledge and resources to facilitate local Outcome meeting the physical activity guidelines (adjusted
control = 5719) involvement in planning, promotion, and delivery OR 1.02, 95% CI: 0.88 to 1.17; P = 0.80). 2) Weak
of a physical activity intervention. evidence of an increase in minutes of moderate-
and-vigorous-intensity activity per week (adjusted
mean difference = 171, 95% CI: -16 to 358;
P = 0.07).
Caprara et al Brazil RCT 10 intervention clusters, 10 Infectious Intervention adopted an eco-health approach to Health 1) Impact on vector densities—overall vector Low
2015 [17] control clusters Disease involve community through workshops, clean-up Outcome density increased from dry season (pre-
campaigns, mobilization of school children and intervention) to the rainy season (post-
seniors, and distribution of information, education intervention) as expected, but the increase was
and communication materials. significantly higher in the control area (p-values:
House Index = 0.029; Container Index = 0.020;
Breteau Index = 0.014, Pupae per person = 0.023)
demonstrating the protective efficacy of the
intervention.
s p d a r Overall
Sansiritaweesook Thailand Intervention 182 informants, 562 Environmental 7-step process used to develop a model for local Health 1) In the year after system implementation the non- Medium
et al 2015 [16] study surveillance networks, 21,234 Health drowning surveillance system based on community Outcome fatality drowning rate in target areas fell to zero, the
villagers participation. non-fatality rate in control areas increased. 2)
Fatality rate in target areas dropped to 4.5 per
100,000 but remained the same in control areas.
Incidence rate ratio of injuries in the comparison
areas was 23.32 times higher than in the target areas
(95% CI: 3.081–176.599, p = 0.002).
Hoelscher et al United Intervention 15 schools receive BPC Healthy Living School-based obesity prevention program (CATCH Health 1) In terms of percentage of students classified Unclear

2010 [20] States study intervention, matched with 15 BP) versus complimentary program (CATCH BPC) Outcome overweight or obese, CATCH BP had a decrease of
schools that receive BP only that formed partnerships with external community 1.3 points (3.1%) (P = 0.33) while CATCH BPC had
organizations. a decrease of 8.3 points (8.2%) (P<0.005).
Sharpe et al Canada Intervention 40 after-school program sites Healthy Living CATCH Kids Club (CKC) program integrated into Health 1) Nearly all sites, with the exception of the BCG Unclear
2011 [64] Study [6 BGC CKC sites, 12 the programming of 2 agencies–the YMCA and the Outcome baseline program (a sports program) achieved
comparison sites] Boys and Girls Clubs (BGC). greater than 50% of time spent in moderate to
vigorous physical activity (MVPA). 2) Significant
differences were not found between levels of MVPA
at intervention and comparison sites (59.3% vs.
64.2%) or at intervention sites at baseline vs. post
intervention (59.3% vs. 52.1%). 3) BCG sites had
significantly higher levels MVPA in CKC programs
than in sports programs (70.8% vs. 35.2%).
Clark et al United Intervention 1,477 parents of children with Non Allies Against Asthma program—a 5-year Health 1) At follow-up, Allies children experienced Unclear
2014 [22] States study asthma in coalition target Communicable collaborative effort by 7 community coalitions Outcome significantly fewer daytime symptoms than did
areas and comparison areas Disease designed to change policies regarding asthma comparison children over the preceding 2 weeks
management in low-income communities of color. (3.03 vs. 3.91; p = 0.008). 2) Annual differences in
daytime symptoms were not evident. 3) Night time
symptoms over the preceding 2 weeks (2.35 vs. 3.41;
p = 0.004) and 1 year (55.17 vs. 81.45; p = 0.003)
were significantly less frequent among Allies
children than among comparison children. 4) 29%
of Allies children went from experiencing some
symptoms at baseline, to experiencing no
symptoms at follow-up. In comparison group, 19%
of children became symptom free. 5) After
adjustment for race/ethnicity, age, gender, and
community site, the Allies children had 2 times the
odds of comparison group of moving from some
symptoms at base-line to none at follow-up (odds
ratio = 1.9; 95% CI = 1.17, 2.96).
(Continued)
16 / 25
Clark et al 2013 United Intervention 12,361 in intervention group, Non 6 Allies Against Asthma coalitions mobilized Health 1) Allies Children were significantly less likely Medium
[65] States study 14,475 in comparison group Communicable stakeholders for policy change in asthma control. Outcome (p<0.04) to have an asthma related hospitalization,
Disease and less likely (p<0.02) to have such healthcare use.
2) The hazard of having a hospitalization, ED, or
urgent care visit at any time during the 5-year time
period was 6% to 7% (p<0.01 and p<0.02) greater
for children in the comparison group than those in
the Allies communities.
s d n c Overall
Davison et al United Cohort 423 children age 2–5 Healthy Living CBPR used to develop and pilot test a family- Health 1) Compared with pre-intervention, children at Low
2013 [46] States centered intervention for low-income families with Outcome post intervention exhibited significant
preschool-aged children. improvements in their rate of obesity, light physical
activity, daily TV viewing, and dietary intake
(energy and macronutrient intake). 2) Positive
trends observed for BMI z score, sedentary activity
and moderate activity.
Reeve et al Australia Cohort N/A Non A health service partnership between an Aboriginal Health Long-term outcomes– 1) Decreased number of Medium
2015 [25] Communicable community-controlled health service, a hospital, Outcome deaths and emergency admissions. 2) Increased
Diseases and a community health service that implemented screening for alcohol and tobacco use.
an integration of health promotion, health
assessments, and chronic disease management.
Oba et al Thailand Cohort 160 pre-diabetes patients Non Community participation in 5 processes of the Health 1) After intervention, the mean score for exercise Medium
2011 [66] Communicable assessment, diagnosis, planning, implementation, Outcome activity among the persons with pre-diabetes was
diseases and evaluation of a diabetes health promotion significantly higher (before 2.72 +/- 1.24 SD; after
program in a primary care unit. 3.00 +/- 0.980 SD; paired t-test -2.95; p = 0.004). 2)
The mean score for BMI was lower after
intervention (before 24.83 +/- 4.47 SD; after 24.38
+/- 4.330; paired t-test 4.77; p = 0.001). 3) The
mean score for waist circumference was lower after

intervention (before 83.34 +/- 9.12 SD; after 81.66
+/- 8.830; paired t-test -2.95; p = 0.004). 4) The
mean score for systolic blood pressure was lower
after intervention (before 128.45 +/- 13.94; after
125.84 +/- 10.632; paired t-test 2.67; p = 0.008).
Overall, this meant that community participation
provided proactive services to persons with pre-
diabetes.
Barnes et al United Case Study Not mentioned Non Users of a community mental health inter- Health 1) The service users with whom the students worked (n = 72) N/A
2006 [43] Kingdom Communicable professional training program (partnerships with Outcome improved significantly over 6 months in terms of their social
Diseases service users) involved in the commissioning, functioning [F (1,62) = 4.12, p = 0.047] and life satisfaction [F
management, delivery, participation, and (1,59) = 6.43, p = 0.014], but not in their mental health status [F
evaluation of the program, as trainers and as course (1,65) = 0.85, p = 0.352]. 2) Users in the comparator groups also
members. improved in life satisfaction and social functioning, but the
improvement in social functioning was significantly greater for
those users in the program group than for the comparators [F
(3,155) = 7.31, p< 0.001].
King et al American Case Study 50 representatives from Infectious Modified the initial Mass Drug Administration Health 1) After the MDA program change coverage increased from 49% to N/A
2011 [55] Samoa churches interviewed Disease (MDA) strategy and partnered with various Outcome 71% and remained high in subsequent years. Reported compliance
community groups including church groups for for people living in surveyed households was 86.4% (95%CI, 83.8–
drug distribution, dissemination of messages about 88.9%). 2) 94.6% of respondents reported taking tablets at least
prevention of LF, and to encourage compliance. once since program inception, 73.6% reported taking tablets every
Developed radio and television ads to encourage MDA and 81.6% reported taking tablets during the last MDA
"pill taking" and advertising locations of (2004); among those who took tablets in 2004, 82.6% received prior
distribution. notification, an improvement from 2003 (x2 = 7.4; p<0.01).
17 / 25
health impact assessment among native participants reported otherwise, highlighting the need to
account for a community’s history of colonization and forced assimilation in the community
engagement process [57]. At a more fundamental level, community participation has been per-
ceived to have facilitated community ownership and development as reported in two studies [57,
62].
Empowerment
studies that report on empowerment can be found in Table 9 (See S1 File for table legend for
risk of bias).
Three studies described how participation in a community initiative fostered engagement
[28, 42, 53]. Two studies described how greater agency, i.e. the capacity of individuals to act on
their own accord, interacted with empowerment [15, 29]. One study involved a volunteer-
based community health advisory program that sought to increase access to health services
which reported a sense of empowerment among participants after they were given greater con-
trol over program direction [29]. The other study, involving a youth advisory board formed
through CBPR, reported an improved sense of agency amongst students [15]. One study
described specifically how gaining skills through participation led to empowerment. The study
involved a community-academic collaboration that led to resident empowerment through
skills based training that was included in the CBPR research process[28]. In another study on
active participation strategies for environmental solutions, community groups were reportedly
mobilized to make changes in their own community, resulting in the strengthening and
empowerment of the community [42].
Health outcomes
studies that report on health outcomes can be found in Table 10 (See S1 File for table legend
for risk of bias).
The health impact of community participation interventions was the most evident among
studies involving non-communicable diseases. All five studies reported positive health out-
comes including decreased hospital admissions [25, 65], reduced clinical symptoms [22],
improved behavioral risk factors such as exercise [46, 49, 64, 66], improved quality of life[43],
and decreased mortality over time [16]. Two studies on infectious diseases reported positive
health outcomes in terms of greater community compliance to the prevention and treatment
of lymphatic filariasis which was the targeted disease of the community participation program
[55], and a lower rate of increased vector density of a dengue control intervention[17]. Two
out of 4 studies relating to healthy living reported positive results relating to improvements in
obesity rates [20, 46], while the other 2 studies targeting physical activity did not find these
interventions effective in promoting health outcomes [49, 64]. Only one study on environmen-
tal health reported on health outcomes where the implementation of the local drowning sur-
veillance system resulted in reductions in non-fatal drowning rates, drowning fatality rates
and incidence rate ratios of injuries [16].
Discussion
This review explores reported outcomes of community involvement and participation and
presents a conceptual model to frame these outcomes, beginning with a foundation of process
outcomes and community outcomes as necessary to achieving robust health outcomes, while
recognizing the influence of stakeholder perspectives and empowerment.

Our review highlights the importance of both process and outcomes evaluations when
assessing community involvement interventions. Process outcomes, especially those that
reflect on organizational processes, are the results of intra- and inter- organizational negotiat-
ing and learning, that over time results in “trust” and “authentic” relationships which ulti-
mately drive partnerships forward [66]. Few studies report on the community processes that
result from these initiatives, such as increased outreach, volunteerism or other “conversion” of
community members into active members. From an organizational perspective, many studies
reported on the learning phases wherein organizational relationships are established and built.
Partnerships in this phase mostly report process outcomes as they learn ways of working both
together and with the community [43]. This learning curve is important in developing contex-
tually appropriate interventions and those studies that invest in this stage report success in
program development and implementation [25].
Failing to account for contextual learning can result in failure to work together to achieve
goals, and this is especially important in vulnerable populations and those communities with a
history of colonization and forced assimilation [55]. This speaks to the international Aborigi-
nal self-determination movement which calls for program development for indigenous people
by indigenous people that integrates underlying theoretical and cultural frameworks into
applied public health [17]. Past research has shown how community participation interven-
tions have been viewed as an initiative to improve health outcomes rather than a process to
implement and support health program to sustain these outcomes [20, 46]. However, our find-
ings highlight that examining community participation as a “process” is equally as important,
and furthers the understanding that outcomes could be influenced by shifts in social, eco-
nomic, and political contexts over time.
Overall, community-level outcomes were the most common measure reported across the
studies. Findings from our review demonstrate that successful community outcomes were
most evident among interventions that included outreach activities such as: health camps,
community fairs, and partnerships with schools and religious groups [49, 64]; targeted inter-
ventions that delivered tailored and specific health knowledge [16]; and interventions that
encouraged relationship building with the wider community [28, 41, 44]. CBPR was also bene-
ficial in developing trust between community and academic partners through the creation of a
level-playing environment where members could decide on health priorities collectively [28,
29, 67]. In another review that examined the effectiveness of community engagement in health
intervention planning and delivery, community participation initiatives were reportedly linked
to positive gains in social capital, social cohesion, and in capacity building among the commu-
nity [16, 22]. Furthermore, a systematic review addressing what indigineous Australian clients
valued about primary health identified how community participation influences access,
acceptability, availability, responsiveness and quality of services, with the potential of increas-
ing utilisation and ultimately improving health outcomes [68]. Another study also identified
how increased community participation could also address the social determinants of health
outcomes through increased local or Indigenous employment services [69]. In our review
however, very few studies reported on such community outcomes, which are inherently more
difficult to define and measure given its subjectivity.
In terms of population level outcomes, our findings indicate that there is a problematic reli-
ance on empowerment as an outcome measure of community participation interventions.
Some studies report on community empowerment and empowering of participants as a com-
munity level improvement resulting from participation in a community project or initiative
[67]. Empowerment is perceived as beneficial and a positive outcome of community participa-
tion, often constructed through qualitative exploration of participants and residents’ percep-
tions, but without a robust definition and measurement of impact, caution is required in

attributing the outcomes reported to actual community empowerment. Furthermore, care

must be taken not to reduce empowerment to a component of a bureaucratic process while
conflating these debatable definitions and measures of empowerment to represent tangible
power and influence [70]. Empowerment as an outcome requires sustained community
engagement, which is dependent on program sustainability. While there may be many barriers
to sustainability, the greatest challenges can be political [71].
Findings from our review indicate that the ultimate aim for most community involvement
programs is to improve health and wellbeing of a particular community; however, indicators
were difficult to obtain and measure. Changes in health status usually require long-term moni-
toring and may not be measurable over a single program cycle. In our review, health outcomes
are most commonly reported for community involvement interventions addressing non-com-
municable diseases and healthy living, and findings presented are generally mixed. For
instance, some healthy living interventions reported no significant effect of physical activity
interventions on health outcomes [15, 17, 24, 46, 55, 57] while others reported the contrary
[22, 65]. Nonetheless, interventions that are contextually targeted which have specific goals at
the outset that are monitored over time seem to have greater success in achieving positive
health outcomes [16, 44, 54]. As highlighted in other reviews, identifying that a positive out-
come or change is specifically attributable to community participation is a complex task [44].
Community participation initiatives usually do not happen as a direct and linear intervention
to improve health, but rather consists of complex processes and interactions [7]. Our review
reports promising evidence that community engagement has a positive impact on health, espe-
cially when supported by a strong organizational and community foundation.
Despite the variability in interventions, there are some positive community participation
examples that provide convincing evidence of benefits as demonstrated by the six RCTs identi-
fied in this review, two of which were of high quality given its overall low risk of bias [17–19,
48–50]. Boivin’s study elucidates that community involvement is central to setting priorities in
driving healthcare improvement at the population level [19] while Caprara’s study presents
social participation as an effective tool in facilitating environmental management for improved
dengue vector control [17]. It should be noted however, that all studies described were context
specific, hence the external validity of these studies are inevitably limited. Ultimately, there is
‘no one size fits all’ approach to community participation that will ensure intended positive
outcomes and community participation that is tailored to context is fundamental in ensuring
the provision of equitable health care and optimization of interventions to improve health
[64].
Strengths and limitations

This systematic review on outcomes of community participation in high and upper middle
income countries is the first of its kind to be conducted. A strength of this review was the use
of a wide range of databases and the inclusion of papers in multiple languages to ensure broad
representation. However, majority of the studies identified were conducted in the United
States which could be a result of publication bias. It is highly likely that not many real world
community participatory initiatives are evaluated robustly according to epidemiological stan-
dards, and it is possible that studies with null findings are less likely to be published. Addition-
ally, given the broad scope of our inclusion criteria, the search produced a large amount of
literature on community participation for eligibility assessment and synthesis. Nevertheless,
prioritizing studies that had the best quality evidence in outcomes reported allowed for the
data extraction and synthesis process, and the risk of bias assessment, to be done comprehen-
sively and with rigour.

Implications for research. Our review shows that while community participation and
involvement is well documented from a case study and qualitative perspective, there is a need
for more robust program evaluations and studies that measure and report long-term out-
comes. Studies were largely descriptive or only had a evaluative component as part of a case
study. While descriptive reports provide insight into program successes and operationalisation
they would benefit from more robust methodology and reporting to determine stronger causal
linkages between intervention components and desired outcomes.
Our review included six RCT studies that serve as positive examples for evaluating commu-
nity participation programs. However, it must be noted that while RCTs are considered the
gold standard in research methodology; difficulties in applying experimental designs at the
population level is evident and well documented [7]. A particular challenge will be to account
for the multi-faceted health and social dimensions of community participation in drawing
definitive linkages and pathways that explain how community participation leads to a desired
community or health outcome[6].
Importantly, no studies reported on outcomes relating to costs. Further evaluations are
needed to examine the cost-effectiveness of real-world interventions and draw comparisons
between the varying approaches of community participation and involvement. Such research
is imperative to support evidence-based policy-making by identifying community participa-
tion programs that can achieve the greatest health return on investment.
Implications for policy

Evidence garnered from this systematic review presents some of the successes of community
participation in yielding positive outcomes at the organizational, community, and individual
level in high and middle-income countries. It is a worthwhile endeavour for policymakers to
devote resources in enabling community engagement, creating platforms for involvement, and
in facilitating successful collaborations or partnerships within the health sector and beyond.
Nonetheless, addressing issues of power relations, developing trust with the community, and
understanding the political, social, and economic contexts in which initiatives are supported,
is imperative in any form of community engagement effort.
Based on the findings of this review, we have developed a new outcomes framework for
community participation which policy-makers can utilise to prioritise program outcomes and
justify resource allocation in program design and implementation. Consideration of the inter-
play of social and cultural factors is essential when exploring perspectives of community mem-
bers on outputs of such initiatives, while empowerment and power relations are key elements
that should be taken into account with more robust measurements. As policy-makers consider
new and effective ways of planning, implementing, monitoring, and evaluating community
involvement programs, the evidence here can contribute in providing some clarity to the pro-
cess and supporting the development of evidence based policies.
Conclusion
Community participation is a fundamental element of an equitable and rights-based approach
to health that is proven effective in optimizing health interventions for positive public health
impact. This review adds to this evidence base supporting the utility of community participa-
tion in yielding positive outcomes at the organizational, community, and individual level
across a wide range of health domains. Our findings present process and community outcomes
as necessary to achieving robust health outcomes. This supports the notion that participatory
approaches and health improvements do not happen as a linear progression, but rather con-
sists of complex processes influenced by an array of contextual factors. Overall, it is evident

that community involvement is key in priority setting to drive healthcare improvement and
that interventions utilizing community involvement can benefit from a contextualizing learn-
ing phase whereby organizational relationships and trust can develop. Our review highlights
the need for more robust program evaluations of community participation initiatives that
measure long-term outcomes and cost-effectiveness, in more settings globally.
Supporting information
S1 Table. PRISMA checklist.
(DOCX)
S1 File. Legend for outcome tables.
(DOCX)
Author Contributions
Conceptualization: Victoria Haldane, Fiona L. H. Chuah, Helena Legido-Quigley.
Data curation: Victoria Haldane, Fiona L. H. Chuah, Aastha Srivastava, Shweta R. Singh,
Helena Legido-Quigley.
Formal analysis: Victoria Haldane, Fiona L. H. Chuah, Aastha Srivastava, Shweta R. Singh,
Helena Legido-Quigley.
Supervision: Helena Legido-Quigley.
Writing – original draft: Victoria Haldane, Fiona L. H. Chuah, Gerald C. H. Koh, Chia Kee
Seng, Helena Legido-Quigley.
Writing – review & editing: Victoria Haldane, Fiona L. H. Chuah, Gerald C. H. Koh, Chia
Kee Seng, Helena Legido-Quigley.
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RESEARCH ARTICLE

Community participation in health services

Accepted: April 15, 2019 Methods and findings

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Table 1. Medline search string.

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Fig 1. PRISMA flowchart.

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Characteristics of included studies

Outcome definitions and framework

Table 2. Categories of community involvement initiatives (n = 49).

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Fig 2. Study location by category.

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Table 3. Outcomes definitions.

Table 4. Definitions of empowerment reported in studies included.

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Fig 3. Community participation outcomes framework.

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Table 5. Outcomes by study design and disease category.

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attributing the outcomes reported to actual community empowerment. Furthermore, care

Strengths and limitations

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Implications for policy

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